Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END Q0114 FERN TEST $9.88 20060701 99999999 Q0115 POST-COITAL DIRECT, QUALITATIVE EXAMINATIONS OF VAGINAL OR CERVICAL MUCOUS $13.68 20060701 99999999 Q0117 FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND SUPPLY $58.20 19990701 99999999 Q0128 ETOPOSIDE; ORAL, 50 MG $18.22 19990701 99999999 Q3004 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, XENON XE 133, PER 10 MCI $40.00 20040101 99999999 Q3008 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, INDIUM 111-IN PENTETREOT $1,500.00 20040101 99999999 Q3009 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC99M OXIDRON $1.47 20010101 99999999 Q3010 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC99M - LABEL $55.00 20040101 99999999 Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE $20.00 20020101 99999999 Q3020 ALS VEHICLE USED, NON-EMERGENCY TRANSPORT, NO ALS LEVEL SERVICE FURNISHED $102.38 20031016 99999999 Q4005 CAST SUPPLIES, LONG ARM CAST, ADULT (11 YEARS +), PLASTER $6.50 20020101 99999999 Q4006 CAST SUPPLIES, LONG ARM CAST, ADULT (11 YEARS +), FIBERGLASS $20.00 20020101 99999999 Q4008 CAST SUPPLIES, LONG ARM CAST, PEDIATRIC (0-10 YEARS), FIBERGLASS $10.36 20020101 99999999 Q4009 CAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), PLASTER $6.14 20020101 99999999 Q4010 CAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), FIBERGLASS $14.20 20020101 99999999 Q4012 CAST SUPPLIES, SHORT ARM CAST, PEDIATRIC (0-10 YEARS), FIBERGLASS $6.92 20020101 99999999 Q4014 CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND HAND), ADULT (11 YEARS $18.88 20020101 99999999 Q4016 CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND HAND), PEDIATRIC (0-10 $9.44 20020101 99999999 Q4017 CAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), PLASTER $6.47 20020101 99999999 Q4018 CAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), FIBERGLASS $10.32 20020101 99999999 Q4020 CAST SUPPLIES, LONG ARM SPLINT, PEDIATRIC (0-10 YEARS), FIBERGLASS $5.16 20020101 99999999 Q4021 CAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), PLASTER $4.79 20020101 99999999 Q4022 CAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), FIBERGLASS $8.64 20020101 99999999 Q4024 CAST SUPPLIES, SHORT ARM SPLINT, PEDIATRIC (0-10 YEARS), FIBERGLASS $3.11 20030101 99999999 Q4028 CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), PEDIATRIC (0-10 YEARS), FIBERGLASS $24.00 20020101 99999999 Q4030 CAST SUPPLIES, LONG LEG CAST, ADULT (11 YEARS +), FIBERGLASS $38.92 20030101 99999999 Q4031 CAST SUPPLIES, LONG LEG CAST, PEDIATRIC (0-10 YEARS), PLASTER $10.27 20020101 99999999 Q4037 CAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), PLASTER $11.69 20020101 99999999 Q4038 CAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), FIBERGLASS $20.00 20020101 99999999 CAST SUPPLIES, SHORT LEG CAST, PEDIATRIC (0-10 YEARS), Q4040 FIBERGLASS $14.20 20020101 99999999 Q4045 CAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), PLASTER $5.94 20030101 99999999 CAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), Q4046 FIBERGLASS $13.27 20020101 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 78
PROC-CODE DESC MAC BEG END Q4047 CAST SUPPLIES, SHORT LEG SPLINT, PEDIATRIC (0-10 YEARS), PLASTER $4.12 20020101 99999999 Q4049 FINGER SPLINT, STATIC $1.50 20020101 99999999 Q9949 LOW OSMOLAR CONTRAST MATERIAL, 300-349 MG/ML IODINE CONCENTRATION, PER ML $0.36 20060101 99999999 Q9950 LOW OSMOLAR CONTRAST MATERIAL, 350-399 MG/ML IODINE CONCENTRATION, PER ML $0.23 20060101 99999999 Q9965 LOW OSMOLAR CONTRAST MATERIAL, 100-199 MG/ML IODINE CONCENTRATION, PER ML $1.81 20080101 99999999 Q9966 LOW OSMOLAR CONTRAST MATERIAL, 200-299 MG/ML IODINE CONCENTRATION, PER ML $1.14 20080101 99999999 Q9967 LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML $0.30 20080101 99999999 R0070 TRANS OF PORTABLE XRAY EQ AND PERSONNEL TO HOME OR NH PER TR $67.71 19990701 99999999 R0075 TRANS OF PORTABLE XRAY EQ AND PERSONNEL TO HOME OR NH PER TR $28.68 19990701 99999999 S9999 SALES TAX $0.01 20000101 99999999 T1005 RESPITE CARE SERVICES, UP TO 15 MINUTES $78.70 20020101 99999999 T1013 SIGN LANGUAGE OR ORAL INTERPRETER SERVICES $9.36 20030401 99999999 T1016 CASE MANAGEMENT, EACH 15 MINUTES $336.00 20031001 99999999 T1017 TARGETED CASE MANAGEMENT, EACH 15 MINUTES $28.00 20030101 99999999 T1021 HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT, PER VISIT $20.00 20031001 99999999 T1030 NURSING CARE, IN THE HOME, BY REGISTERED NURSE, PER DIEM $50.00 20031001 99999999 T1999 MISCELLANEOUS THERAPEUTIC ITEMS AND SUPPLIES, RETAIL PURCHASES, NOT OTHERWISE CL $31.47 20031116 99999999 T4521 ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, SMALL, EACH $0.62 20050101 99999999 T4522 ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, MEDIUM, EACH $0.66 20050101 99999999 T4524 ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, EXTRA LARGE, EACH $0.69 20050101 99999999 T4541 INCONTINENCE PRODUCT, DISPOSABLE UNDERPAD, LARGE, EACH $0.30 20050101 99999999 V2020 FRAMES, PURCHASES $20.12 20060701 99999999 V2025 DELUXE FRAME $55.00 19920101 99999999 V2100 SPHERE SINGLE VISION PLANO TO PLUS OR MINUS 4.00 PER LENS $25.27 20060701 99999999 V2101 SPHERE SNGL VISION PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D $28.63 20060701 99999999 V2102 SPHERE SGL VISION PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00D $36.18 20060701 99999999 V2103 SPHEROCYLINDER SGL VISION PLANO TO PLUS OR MINUS 4.00D SPHER $25.15 20060701 99999999 V2104 SPHEROCYLINDER SGL VISION PLANO TO PLUS OR MINUS 4.00D SPHER $24.82 20060701 99999999 V2105 SPHEROCYL SGL VISION PLANO TO + OR - 4.00D 4.25 TO 6.00D CYL $25.15 20060701 99999999 V2106 SPHEROCYL SGL VISION PLANO + OR - 4.00D SPHERE 6.00D PER LEN $29.15 20060701 99999999 V2107 SPHEROCYL SGL VISION + OR - 4.25 TO + OR - 7.00,.12 TO 2.00D $30.54 20060701 99999999 V2108 SPHEROCYL SGL VISION + OR - PER LENS $28.79 20060701 99999999 V2109 SPHEROCYL SGL VISION + OR - PER LENS $33.20 20060701 99999999 V2110 SPHEROCYL SGL VISION + OR - PER LENS $28.18 20060701 99999999 V2111 SPHEROCYL SGL VISION + OR - PER LENS $33.21 20060701 99999999 V2112 SPHEROCYL SGL VISION + OR - PER LENS $35.14 20060701 99999999 V2113 SPHEROCYL SGL VISION + OR - PER LENS $27.74 20060701 99999999 V2114 SPHEROCYL SGL VISION OVER + OR - PER LENS $32.17 20060701 99999999 V2115 LENTICULAR (MYODISC) PER LENS SINGLE VISION $83.47 20060701 99999999 V2116 LENTICULAR LENS NONASPHERIC PER LENS SINGLE VISION $83.47 20030401 99999999 V2117 LENTICULAR ASPHERIC PER LENS SINGLE VISION $83.47 20030401 99999999 V2118 ANISEIKONIC LENS SINGLE VISION $90.89 20060701 99999999 V2121 LENTICULAR LENS, PER LENS, SINGLE $69.31 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 79
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